Feb. 20. 2013 11:28AM FL Builders Appliance Sarasota No.5221 =P. 1/7 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. AHCA No. 2012012786 JEANNIE'S PLACE, INC. d/b/a JEANNIE’S PLACE,! Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Jeannie's Place, Inc. d/b/a Jeannie’s Place (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate this assisted living facility based upon violations of state law. * According to the Florida Division of Corporations website, this fictitious name is not registered. Under Florida Jaw, a person may not engage in business under a fictitious name unless the person first registers the name with the division by filing a sworn statement listing: (a) The name to be registered. (b) The mailing address of the business. (c) The name and address of each owner and, if corporation, its federal employer's identification number and Florida incorporation or registration number. (d) Certification by the applicant that the intention to register such fictitious name has been advertised at least once in a newspaper as defined in chapter 50 tn the county where the principal place of business of the applicant will be located. (e) Any other information the division may deem necessary to adequately inform other governmental agencies and the public as to the persons so conducting business. Such statement shall be accompanied by the applicable processing fees and any other taxes‘or penalties owed to the state. § 865.09(3), Fla. Stat. (2011). Under Florida law, if'a business fails to comply with this section, the business, its members, and those interested in doing such business may not maintain any action, suit, or proceeding in any court of this state until this section is complied with. An action, suit, or proceeding may not be maintained in any court of this state by any successor or assignee of such business on any right, claim, or demand arising out of the transaction of business by such business in this state until this section has been complied with. § 865.09(9), Fla. Stat. (2012). Feb, 20, 2013 11:28AM FL Builders Appliance Sarasota No 5221 P. 2/7 PARTIES 1. The Agency is the licensing and regulatory authority that oversees assisted living facilities in Florida and enforces the applicable state statutes and rules governing such facilities. Ch, 408, Part II, Ch. 429, Part I, Fla. Stat. (2012); Ch. 584-5, Fla. Admin. Code. The Agency , may deny, revoke, and suspend any license issued to an assisted living facility and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or applicable rules, §§ 408.813, 408.815, 429.14, 429.19, Fla, Stat. (2012). In addition to licensure denial, revocation or suspension, or any administrative fine imposed, the Agency may assess a survey fee against an assisted living facility, § 429,19(7), Fla. Stat, (2012). 2. The Respondent was issued a license by the Agency to operate an assisted living facility located at 4656 West 10 Avenue, Hialeah, Florida 33012 (“the Facility”), and was at all times material required to comply with the applicable statutes and rules goveming assisted living facilities. Assisted living facilities are residential care facilities that provide housing, meals, personal care and supportive services to older persons and disabled adults who are unable to live independently. These facilities are intended to be a less costly alternative to the more restrictive, institutional settings for individuals who do not require 24-hour nursing supervision. Assisted living facilities are regulated in a manner so as to encourage dignity, individuality, and choice for residents, while providing them a reasonable assurance for their health, safety and welfare. Genetally, assisted living facilities provide supervision, assistance with personal care and Supportive services, as well as assistance with, or administration of, medications to residents who require such services. Feb. 20. 2013 {1:28AM FL Builders Appliance Sarasota No. 5221 P. 3/7 COUNT I Terminated For Cause From State Medicaid Program 3. Under Florida law, in addition to the grounds provided in authorizing statutes, grounds that may be used by the Agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest: ... (¢) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the state Medicaid program, the Medicaid program of any other state, or the Medicare program. § 408.815(1)(e), Fla. Stat. (2012). 4, On November 5, 2012, the Agency terminated Leo Homes, Inc. for cause from, the state Medicaid program by way of Final Order issued by the Agency in Case No, CI 130301000, Provider Number 006277700. 5, Leonard Sifredo is a controlling interest in Leo Homes, Inc. 6. Leonard Sifredo is a controlling interest in Jeannie’s Place, Inc. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondents license. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to enter a final order granting the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency. 2. Impose the relief against the Respondent as set forth above. Respectfully submitted on this 4" day of February, 2013. Respectfully Submitted, Feb. 20. 2013 11:28AM FL Builders Appliance Sarasota No. 5221 =P. 4/7 Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, M$3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 Jobn.Bradley@ahca.myflorida.com NOTIC The Respondent is notified of the right to request an administrative hearing pursuant to Sections 120.569 and 120,57, Florida Statutes. If the Respondent wants to hire an attorney, it has the right to be represented by an attorney in this matter at its own expense. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights were served on the persons below on this 4" day of February, 2013. Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan, Drive, Suite 3431 Fort Knox Building 3, M83 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 Feb. 20. 2013 11:28AM FL Builders Appliance Sarasota No. 5221 =P. 5/7 John.Bradley@ahcamyfloridacom Copies: Leonor Sifredo, Administrator/ Shaddrick Haston, Unit Manager Registered Agent (Electronic Mail) Jeannie’s Place, Inc, ‘| 4356 West 10" Avenue Hialeah, Florida 33012 Certified Mail — 7008 1300 0000 6174 2869 Feb. 20. 2013 11:28AM FL Builders Appliance Sarasota No 5206/7 FILED AHC AGENCY CLERK STATE OF FLORIDA , AGENCY FOR HEALTH CARE ADMINISTRATION /013 FEB 26 A I}: 4 u: Re: JEANNIE'S PLACE, INC. d/b/a JRANNIE’S PLACE AHCA No, 2012012786 ELECTION GHTS This Election of Rights form is attached to a proposed agency action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine ot Administrative Complaint. Your Election of Rights may be teturned by mail or by facsimile transmission, but must b ith the Agency Clerk within 21 dayg by 5:00 p.m. Eastern Time, of the day that you receive the attached proposed agency action, If your Election of Rights with your selected option ts not received hy AHCA within 21 days of the day that you received this proposed Agency action, you will have waived your right to contest the proposed agency actlon and a Final Order will be issued. . (Please use this form unless you, your attomey or your representative prefer to reply according to Chapteri20, Florida Statutes, and Chapter 28, Florida Adainistrative Code.) Please return your Election of Rights to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone; 850-412-3630 Facsinoile: 850-921-0458 PLEASE SELECT ONI sY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to lupose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing, I understand that by giving up my sight to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. . OPTION TWO (2) T admit to the allegations of facts contained in the Notice of Tatent to Impose a Late Fee, Notice of Intent fo Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120,57(2), Florida Statutes) where L may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced, OPTION THREE (3) vA I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal heartag (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Divigion of Administrative Hearings, Feb. 20. 2013 11:28AM FL Builders Apoliance Sarasota No, 5221 P.T/T PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 24 days of your receipt of this proposed agency action. The request for formal hearing must conform to the Tequirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. Thename, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. . . 3. A statement requesting an administrative hearing identifying those material facts that are in dispute, If there are none, the petition must so indicate. ‘ 4, A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency - agrees, Licensee Name: “Teomnie’s Cone Sune. ‘ | | ‘ont on: On , CC PCH othe dent Tees OfGces om Vi Ae CHe.c ress: ve... Ar we. 33/2! Ades 2323. Beiebel Ave... Ste.A F Mirus Fl. 33/ 9 City Zip Code _ Telephone No, S0S- 35 ‘ “450 Fax No. 308° 35%-SH/3 E-Mail (optional) _eparrella@vitaleherltilans. com T hereby certify that I am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on 1) of the licensee referred to above. Date:_ 2°29 7: 13 Title: TY, a H¢0,¢ PL,CECO . upon recemt of Natice Signed: Printed Names by le ; GA Moten for Buaal®. hep. wi STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, y. AHCA No. 2012012786 JEANNIE'S PLACE, INC, d/b/a JEANNIB’S PLACE, | Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Jeannie's Place, Inc. d/b/a Jeannie’s Place (“the Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes (2012), and alleges: NATURE OF THE ACTION This is an action to revoke the Respondent’s license to operate this assisted living facility based upon violations of state law. " According to the Florida Division of Corporations website, this fictitious name is not registered. Under Florida Jaw, a person may not engage in business under a fictitious name unless the person first registers the name with the division by filing a sworn statement listing: (a) The name to be registered, (b) The mailing address of the business. (c) The name and address of each owner and, if a corporation, its federal employet’s identification number and Florida incorporation of registration number. (d) Certification by the applicant that the intention to register such fictitious name has been advertised at least once in a newspaper as defined in chapter 50 in the county where the principal place of business of the applicant will be located. (e) Any other information the division may deem necessary to adequately inform other governmental agencies and the public as to the persons so conducting business. Such statement shall be accompanied by the applicable processing fees and any other taxes‘or penalties owed to the state, § 865.09(3), Fla. Stat. (2011). Under Florida law, if business fails to comply with this section, the business, its members, and those interested in doing such business may not maintain any action, suit, or proceeding in any court of this state until this section is complied with. An action, suit, or proceeding may not be maintained in any court of this state by any successor or assignee of such business on any right, claim, or demand arising out of the transaction of business by such business in this state until this section has been complied with. § 864.09(9), Fla, Stat. (2012). PARTIES 1. The Agency is the licensing and regulatory authority that oversees assisted. living facilities in Florida and enforces the applicable state statutes and rules governing such facilities, Ch. 408, Part I, Ch. 429, Part I, Fla. Stat. (2012), Ch. 58A-5, Fla, Admin, Code. The Agency may deny, revoke, and suspend any license issued to an assisted living facility and impose an administrative fine for a violation of the Health Care Licensing Procedures Act, the authorizing statutes or applicable rules. §§ 408.813, 408.815, 429.14, 429.19, Fla. Stat. (2012). In addition to licensure denial, revocation or suspension, or any administrative fine imposed, the Agency may assess a survey fee against an assisted living facility. § 429.19(7), Fla. Stat. (2012). 2. The Respondent was issued a license by the Agency to operate an assisted. living facility located at 4656 West 10 Avenue, Hialeah, Florida 33012 (“the Facility”), and was at all times material required to comply with the applicable statutes and rules governing assisted living facilities, Assisted living facilities are residential care facilities that provide housing, meals, personal care and supportive services to older persons and disabled adults who are unable to live independently. These facilities are intended to be a less costly alternative to the more restrictive, institutional settings for individuals who do not require 24-hour nursing supervision. Assisted living facilities are regulated in a manner so as to encourage dignity, individuality, and choice for residents, while providing them a reasonable assurance for their health, safety and welfare. Generally, assisted living facilities provide supervision, assistance with personal care and supportive services, as well as assistance with, or administration of, medications to residents who require such services. COUNT I Terminated For Cause From State Medicaid Program 3. Under Florida law, in addition to the grounds provided in authorizing statutes, ° grounds that may be used by the Agency for denying and revoking a license or change of ~ ownership application include any of the following actions bya controlling interest: ... (e) The applicant, licensee, or controlling interest has been or is currently excluded, suspended, or terminated from participation in the.state Medicaid program, the Medicaid program of any other state, or the Medicare program, § 408.815(1)(e), Fla, Stat. (2012). 4. On November 5, 2012, the Agency terminated Leo Homes, Inc. for cause from the state Medicaid program by way of Final Order issued by the Agency in Case No. Cr 130301000, Provider Number 006277700. - 5. Leonard Sifredo is a controlling interest in Leo Homes, Inc. 6. Leonard Sifredo is a controlling interest in Jeannie’s Place, Inc. - WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks the revocation of the Respondent’s license. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to enter a final order granting the following relief: 1. Make findings of fact and conclusions of Jaw in favor of the Agency. 2. Impose the relief against the Respondent as set forth above. - Respectfully submitted on this 4” day of February, 2013. Respectfully Submitted, aw JoMn E. Bradley Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John. Bradley@ahca.myflorida.com. NOTICE The Respondent is notified of the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it has the right to be represented by an attorney in this matter at its own expense. Specific options for administrative action are set out in the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights were served on the persons below on this 4™ day of February, 2013. hn E. BeaZ Assistant General Counsel Florida Bar. No. 92277 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building 3, MS3 Telephone: (850) 412-3658 Facsimile: (850) 921-0158 John.Bradley@ahca.myflorida.com Copies: Leonor Sifredo, Administrator/ Shaddrick Haston, Unit Manager Registered Agent (Electronic Mail) Jeannie’s Place, Inc. ‘| 4356 West 10” Avenue Hialeah, Florida 33012 Certified Mail — 7008 1300 0000 6174 2869 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: JEANNIE'S PLACE, INC, d/b/a JEANNIE’S PLACE AHCA No. 2012012786 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights may be returned by mail or by facsimile transmission, but must be filed with the Agency Clerk within 21 days by 5:00 p.m., Eastern Time, of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency action and a Final Order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 — Facsimile: 850-921-0158 ‘PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing, I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) __ I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed agency action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. ; . 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4, A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation. under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No, Fax No. E-Mail (optional) I hereby certify that | am duly authorized to submit this Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. 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Docket for Case No: 13-001243